Third Year Survival Guide 02-2010

Case Med Third Year Survival Guide

February 2010

Introduction: Hello, rising third years (myself included)! As we prepare to make our site selections for our upcoming clerkship rotations, I thought it would be very useful to look at advice from those who have gone before us. This document has been made by working from a previous “Third Year Survival Guide” created by those in the class of ’05. Since our curriculum has changed so much since then, we have recruited those in the class of ’10 and ’11 to help provide specific comments about their rotations. They have taken the time to give us advice and useful information based on their own experiences. That being said, it’s important to remember these are personal opinions, and things are always changing so what you experience might be different. We hope to be able to continually update this useful resource for upcoming years. Also, as mentioned by the previous editor, there may be a few places or experiences that may not have been included or are under‐represented here, so keep that in mind as well, and feel free to explore all your options! You’ll find a Table of Contents on the next page, but the general format is 1) Specialty & Hospital, 2) Useful Resources, 3) Location (Floors), 4) Teams, 5) Call Schedule, 6) Rounds, 7) Lecture, 8) Where to Sleep, 9) Typical Schedule, 10) Pearls of Wisdom, 11) Attendings. Thanks, and good luck! Sharon Santoso ‘12 Introduction from previous version:

Hello. As a greeting and a disclaimer, I would just like to briefly outline the process by which this guide was put together. The information contained herein was solicited from third year medical students, class of aught five, and may certainly contain some personal bias. With that being said however, we attempted to draw out all the pertinent details and information so that future classes would have a better understanding of each location and rotation. Due to the manner in which data was generated, i.e. by solicitation, there are a few places or experiences that may not be included or may be under‐represented in this text. Just remember, one of the best things about Case and the medical system in Cleveland is that there are almost always more options to explore. For those people who find one of those other paths; feel free to update this next year and in years following. I would also like to thank all the contributors to this document and a special thanks to Pooja Agrawal for assisting me and to Dean Linsey Henson for helping guide the project. Also thank you to the authors of the original Year 3 Recommendations Handbook. Best of luck to everyone entering the third year, I think you’ll love it.

Aidan Johnson ‘05

1

Table of Contents General Advice ……………………………………………………………….. 3 Core I Internal Medicine ……………………………………………………… 4 Metro 4 UH/VA 9

CCF 13 St. Vincent 15 Surgery ……………………………………………………………….. 16 Metro 16 UH 20 CCF 23

VA 24 Core II OB/GYN ………………………………………………………………. 25

Metro 25 UH 28

CCF 29 Pediatrics ………………………………………………………………. 30 Metro 31 UH 33 Family Medicine ……………………………………………………. 35 Metro 35

UH 36 CCF 37 Core III Neurology …………………………………………………………….. 37 Metro 38

UH 39 CCF 42 Psychiatry ……………………………………………………………… 42

Metro 42 UH 44 VA (Brecksville) 45 CCF 45

2

General Advice Third year can be a scary time, especially in the beginning when you don’t know your place in the rotation. The best advice I can offer is that you will recoup 10 fold of what you put in. The key to doing well and getting the most out of any rotation is to try to do your best and show a genuine interest in the subject matter even if you have no intention of going into it. Most people care most that you show a genuine interest in the areas of specialty regardless of whether you plan on going into it or not. And your grades are very arbitrary, so don't get upset if they make absolutely no sense. Except for Medicine and Surgery, I did not buy “pocket” reference books for any of my clerkships. If you need to look something up quickly at the hospital, UpToDate is the easiest way to do it. In terms of studying on a daily basis, it depends on your learning style. If you like quick‐facts, the “Recall” series is good. If you like textbooks, you can find the authoritative texts for Medicine, Surgery, Pediatrics, OB/Gyn and Neurology on either AccessMedicine or MDConsult. I am personally not a fan of the Blueprints series, because I think it’s too reductionistic & rarely answers the questions you will be asked on the wards. In terms of studying for the Shelf exams, I think online Qbanks are the best way to go. Advice on dealing with CAS: In my experience (mostly at Metro), residents and attendings do not return CAS feedback in a timely manner, and very rarely include feedback that is actually useful to you in terms of improving your performance on a team (it’s usually “good job” or N/A). You should log all patients you see, but for inpatient services or consult services (Medicine, Peds, Neurology, Psychiatry), assuming you will be with a team for more than 1 week, I suggest sending CAS requests to the attending & senior resident once at the end of each week. This is also valid for your general surgery rotation. However for gyn surg and neurosurg, as well as outpatient experiences, send a request to the attending after the first time you have an interaction with him/her, since you don’t know how many times you may interact with that attending again. For any request, it’s useful if you can include a description of the patient, or, if you have access to the EMR, a copy of one of your notes, to remind them of which patient you are requesting evaluation on. Also, I found that many people still don’t understand the difference between “summative” and “formative” evaluations, so in your request, it’s useful to include some comment like “I appreciate comments about what I did well, but also about how I can improve” so that they know the feedback is for your own benefit, not for your grade. It is useful to have things with you in your white coat, but your pockets can get pretty full really quickly. After the first week or two, you should evaluate what you have been using and what you can dispense with – travel as lightly as possible. Here is a list of stuff that you will find it useful to have on hand to help you answer questions and to look like a well prepared med student.

• Stethoscope • Reflex hammer • Pen light • Palm Pilot (with ePocrates drug database) or pharmecopedia • Notecards • List of normal lab values

3

Internal Medicine Resources: • Blueprints In Medicine – basic but ok • NMS Medicine – very detailed, but good to read for shelf if you have time • Pre‐Test in Medicine—good quick review for shelf (keep in mind the questions for medicine are

ridiculously long, so make sure to pace yourself when studying – lots of people didn’t finish the exam)

• Frank Ferri's Practical Guide to the Care of the Medical Patient – succinct but has all the info you need (pathophysiology, diagnosis, treatment, etc.)

• Step Up to Medicine • Kochar's Clinical Medicine for Students ‐ a very abridged Harrison's with the relevant things to know

for MS3's, more a textbook than a review book, but highly recommended • Pocket Medicine • Internal Medicine Clerkship Guide – “required” for the clerkship at Metro & very useful day‐to‐day

on the wards – organized in terms of presenting symptoms and also in terms of organ system, both sections then have info about associated signs & symptoms, important physical exam signs, labs & imaging, as well as major treatment options

• Washington Manual of Medical Therapeutics – similar format to IM Clerkship Guide, but more detailed

• Medicine Recall • Harrison’s

Metro Overview: • 8 weeks total • 4 weeks on a general inpatient medicine service • 2 weeks outpatient clinic (miscellaneous, sometimes someplace different every half day of the week

plus one half day off) • 2 weeks inpatient “elective” (choose Cardio or Heme/Onc)

o Cardiology: get to really learn how to read EKGs, can specifically request a step‐down unit or possibly a more specific service

o Heme/Onc: less time commitment Location: • General Internal Medicine: patient floors 9A, 9B, 10A, 10B, 10C (each of these floors has 2 teams of

residents/attendings) • For 2‐week electives: Cardiology: 3C; Heme/Onc: 11C Teams: • Each floor has 2 teams: 1 medical student per team plus 1 attending, 1 senior, 2‐3 interns, +/‐ acting

intern Call Schedule: • They say it's supposed to be Q4, but nobody keeps track & the residents don't care, so most people

take 1 call/week. You already miss 2 half‐days/week due to didactics (Wed AM & Fri PM), so each

4

time you’re on call, you are missing another half‐day. Decide for yourself whether you think you learn more in one 30‐hour stint at the hospital, or 2 consecutive 10‐hour days. No call during the 2 weeks of outpatient.

• In May 2009, the schedule was q5 • Class of 2010 – I was q4 with one golden weekend • 1night/week. You don't have to stay overnight but if you do you'll get to leave the next day at noon.

You spend the night w/ one intern from your team picking up new patients (which means doing their history and physical and write‐up) to present the next morning and continue to follow.

Rounds: • Pre‐round prior to daily rounds with senior resident and team at 7 or 7:30, may round with

attending at varying times; teaching rounds with attending twice/week, attendings tend to spend lots of time on the floor with the team

• Usually begin at 8am, but depends on the attending. Arrive early enough to preround on your patients before 8am.

Lecture: • Core 1 Lecture Wednesdays 8am‐12pm • Medicine Resident Lecture daily at 12pm • 1x/wk resident interesting case presentation • Attending teaching lecture in the afternoon 1‐2x/wk for one hour Where to Sleep: • There are lots of available call rooms on floors 9 & 10 Typical Schedule: 7:30‐8am Prerounds (see your patients, get ready to present them at morning rounds) 8‐?? Rounding. How long it takes depends on how your attending likes to do things 11am Task time – get work done on your patient noon Usually there's a Medicine noon conference 1/1:30 Attending will often schedule some didactic time for your team Afternoons are for seeing new patients or following up on stuff for your old patients. You'll finish between 3 & 5pm, depending on whether you have anything to do. 4:30pm This is where the on‐call team takes over. If you are on‐call you will get sign outs from each person about all the patients on the floor. On‐Call This really varied for us. For most of us, however, we were charged to help the intern

take care of all the patients on the floor. This is also the time were you will pick up a new patient or two. Most interns gave the first patient to the medical student so that you have time to sleep later.

Pearls of Wisdom: • You may need to be assertive in order to get the interns to let you "take responsibility" for patients.

The senior resident should assign you patients to admit, but since an intern still has to follow that patient, it's your responsibility to show the intern that you are capable of taking a good history, doing a good exam, and following up on labs/imaging/etc. One drawback of the EMR system at Metro is that med students can no longer write orders (admit orders, etc) for the residents to cosign

5

‐‐ it's just a bunch of clicking on buttons on the computer, and you can't do it unless a resident signs you on under their username.

• The 2 weeks on outpatient are a complete waste of time, because you are never in the same clinic more than twice. Sometimes the attending doesn't even know you're coming, and whether or not they let you see patients on your own is variable. Take advantage of the free time in the evenings to study for the shelf exam.

• The on‐call room on 9c/10/c is REALLY LOUD, you might look into sleeping on 6c if there is room. There’s a hidden student call room on the 11th floor that has windows but is near the lifeflight landing pad so that can be a bit loud.

• Nurses are amazing‐‐‐they can and will teach them‐‐feed them, bring flowers, be nice:) • Get a handbook. I personally think if you have 5 min clinical consult, you are set. • ALWAYS ask the attending to look over a write‐up. If you really want to shine, bring in articles about

your patient and share them with the group. Overall, be proactive about the learning process. • During rounds, take brief notes on anything you don’t know so you can ask your intern or look it up

later. Like most rotations, quality of teaching will depend on the senior and attending. Metro is great because you can really manage your own patients‐‐write all their notes, try to write their orders. All must be co‐signed by a resident but ask your interns to let you try to do as much as possible. There is little to no opportunity to much hands‐on things during the day; instead, use your time overnight to approach nurses/residents about teaching you to give shots, draw blood, etc. Anyone will probably say the same thing, but I think it can't be said enough: 8wks of the wards really can be baptism by fire and really gives you the true taste of what medicine is along with all of the pleasures and frustrations that accompany it. Overall, my experience was a great one, but it was clear to me from others' that it could've also been less than great. What really can decide that is are at least the following few things:

1. Your Attendings 2. Your Teams 3. Your Attitude and work ethic

Since you spend every waking minute with the same people for at least 2 weeks in a row (Attendings @ Metro rotate q 2wks, teams typically rotate q 4 wks), the bottom line to a good experience on the wards is, not surprisingly, teamwork. If anyone on the team doesn't jive well with the rest of the team for whatever reason, the team suffers and can make for a less‐than‐fun time. I was fortunate to work with, overall, knowledgeable, fair attendings and team‐oriented, smart residents and interns who all were very flexible and willing to help each other out in getting the work done. That made bearing the many frustrations of working on the wards much easier. So, a word to the wise ‐ remember that everyone else at the end of the day wants to go home just as badly as you do (maybe more so), and you should help out in any way possible to make that happen: volunteer to run and check labs, x‐rays, and make sure that the things that need to get done at the end of the day are getting done. Residents and interns, especially, will remember that ‐ esp. during evaluations. Metro Int. Medicine Musts: Epic ‐ Metro's computer medical record database. It's imperative that you become familiar with and learn how to use it for accessing charts and patient info.

6

Radiology ‐ Imaging is all on the computer system, PACS. Be sure to have a login for this. Patient Admissions ‐ as soon as you hear that there's an admission from the ER, do NOT wait for the patient to be transported up to your floor; instead, GO TO THE ER TO TAKE THE H&P. Doing so saves a lot of time (it'll on average take around 1‐2 hrs for the patient to be transported) and shows much more initiative/efficiency on your part than waiting around doing nothing. Plus, if you're on‐call, it'll ensure that you get to bed at a decent hour. (When you are in need of picking up a patient, generally you should be following about 3 patients, keep your ears open. When you hear a new patient is coming in, ask the intern if you can follow the patient too. Usually they’ll be happy for the extra help. Certain interns are better about letting you do more work. You’ll figure out your team pretty quick.) Other pointers‐‐pay attention to when your intern has morning clinic (1/week), you can score cool points by taking care of some of this work before lunch. Try to understand the various problems that pts on your teams service are having, you'll probably be asked questions during morning rounds anyway. Bring extra reading materials during outpt monday lectures, some lectures are good, but when they're bad reading something else is better than falling asleep :) I've been using NMS medicine, MKSAP, Guide to internal medicine, Pretest and some OSCE workbook for this rotation.

Attendings: Dr. Blinkhorn: This is probably the most talented teacher/attending I had at Metro. You will probably not round with him but he loves to teach. It will be very worthwhile for you to present a couple patients to him. A few sessions with him could really change your outlook on Medicine. He is respected throughout the hospital. He can be a little intimidating because he is a straight shooter and asks you direct questions, then simply says "No" if you get it wrong. He's a really solid teacher though, keeping things in simple terms and making you think logically. Dr. Curly: OUTSTANDING teacher...she will make sure you know how to read a chest x‐ray...make sure you attend her afternoon rounds on chest x‐rays...these are key! Dr. Erine‐Paul Barrette: Service: 10C Formal teaching (attending rounds, didactic teaching: 4 Informal teaching (work rounds, daily conversation, etc.): 4 Patient care (bedside manner, serving as role model for patient interactions, etc.): 4 Interaction with team members (students and housestaff, other medical team members): 3 Comments: Radiology rounds as a team daily was a valuable learning experience. A traditionalist. Dr. Hanrahan: ‐ ID Attending. hard as nails when you first meet her...ridiculously smart so listen up. She is very driven, pretty serious, and doesn't take any BS from anyone. Although, this is all done for the patients ‐ she cares a lot and has her own way of showing that. Very fair when it comes to grading and don't worry if she doesn't act like she likes you...she doesn't show emotion very often. I had no problems with her personally, but I could see how she might be seen as intimidating. Hope that you can work with her in the clinic, 'cause she's a great teacher. Dr. Lindheim: really an awesome teacher, caring a whole lot about 3rd year students. Dedicates an extra hour most afternoons to teaching us.

7

Dr. Mahan ‐ very good/nice to the team and med students, more laid back about presentation completeness (sometimes he just wants to know the pertinent info). Asks a lot of ID trivia questions; review Microbio Made Ridiculously Simple for the answers (he wrote/edited most of it). Dr. McFarlane: A totally great guy and one of the heads of medicine at metro; awesome and very fair. If you get to work with him, consider yourself very lucky. His knowledge base is ridiculous and his desire to teach really comes through in how he carries out rounds and discussion, so take advantage of that. He won't ask you a question he doesn't believe you should already know. His teaching sessions were good(case based so be prepared to present) and we could all learn alot from him. Dr. Murphy: Service: 10C Formal teaching (attending rounds, didactic teaching: 5 Informal teaching (work rounds, daily conversation, etc.): 3 Patient care (bedside manner, serving as role model for patient interactions, etc.): 5 Interaction with team members (students and housestaff, other medical team members): 4 Comments: You may remember him as the Endocrinology Committee Head from yrs. 1 and 2. Made formal teaching a priority and always came through with an excellent presentation. Overall a pretty good experience, but he WILL pimp you so expect it. Teaching rounds: be sure to prepare the night before for the topic that he will cover. He will also lead some of the 3rd yr teaching sessions, which consist of a round robin question and answer session that puts you in the hot seat. Be nice and tell your fellow students who are post‐call what the topic of the day is so they can prepare. All in all you learn a lot from him. Dr. Quan: Service: 6C Formal teaching (attending rounds, didactic teaching: 4 Informal teaching (work rounds, daily conversation, etc.): 4 Patient care (bedside manner, serving as role model for patient interactions, etc.): 4 Interaction with team members (students and housestaff, other medical team members): 4 Comments: Took role as educator very seriously. I feel much more comfortable now as a result of her on‐the‐spot EKG interpretations. Always available. Dr. Ricanatti ‐ amazingly dedicated to being an attending when on service. Completely there for med students, expects and wants you to act like you are the only person managing your patients. Ask for as much feedback as possible, every single day after every small presentation. Wants a 100% complete formal presentation. Will give you as much attention as you need and ask for. Dr. Robins: Peds Attending who is great ‐ very laid‐back, fun, and extremely fair. She likes to teach and also likes to joke around, and makes for a very fun atmosphere to learn Robins‐young and fun! She's med‐peds and will allow you to get your hands dirty with procedures in her presence as long as your pt. doesn't have HIV (good luck, 90% of my pts. did.) Dr. Rosenberg: really nice guy, solid teacher. Dr. Sadlon: She was good too and was able to write up her notes during morning rounds:) Teaching sessions were concentrated on family medicine. Be prepared to give a 5 minute talk about something related to a problem a pt is having on the team.

Dr. Schelling: Service: 10C

8

Formal teaching (attending rounds, didactic teaching: 4 Informal teaching (work rounds, daily conversation, etc.): 3 Patient care (bedside manner, serving as role model for patient interactions, etc.): 3 Interaction with team members (students and housestaff, other medical team members): 4 Comments: During teaching rounds he made sense of very complex topics. Dr. Shaw: Service: 6C Formal teaching (attending rounds, didactic teaching: NA Informal teaching (work rounds, daily conversation, etc.): 3 Patient care (bedside manner, serving as role model for patient interactions, etc.): 3 Interaction with team members (students and housestaff, other medical team members): 3 Comments: Very approachable. Very efficient.

Dr. Spinelli: Service: 10C Formal teaching (attending rounds, didactic teaching: NA Informal teaching (work rounds, daily conversation, etc.): 3 Patient care (bedside manner, serving as role model for patient interactions, etc.): 3 Interaction with team members (students and housestaff, other medical team members): 2 Comments: Really only interacted with the interns and students when the senior wasn't there. Very quiet person but be prepared to show her a write‐up and have her evaluate it.

Dr. Seeholzer: really an awesome teacher, caring a whole lot about 3rd year students. Dedicates an extra hour most afternoons to teaching us.

Dr. Wiess: ask questions about ID...he is an ID god! Dr. Youseffi: Cardiology Attending. I worked on the telemetry unit for 2 wks with him. Overall he's a great Cardiologist and expects the same level out of his team. He really cares for his patients, and likes to have things done only his way. He takes everything pretty seriously, so do not slack off ‐ he will burn you.

UH/VA UH Location: • Lerner Tower 3‐8, Lakeside 2 and 6 Teams: • Naff/Orange ‐ hospitalist service • Cardiology/general medicine –mostly CHF and MI’s Call Schedule: • Q4 during inpatient months, no call on outpatient Rounds: • Pre‐round 7‐7:30, daily team rounds with senior resident and interns at 8 or 8:30; at least 3

times/week with attending and team; also have teaching rounds with attending

9

Lecture: • Daily medicine lectures at noon with residents with lunch provided most days Where to Sleep: • Share call room with intern/ med student call room in Lakeside VA Location: • Ward 42 and 44 Teams: • 2 teams / ward ‐ senior resident and 2 interns/ team, 2 wards Call schedule: • Q4 during inpatient months, no call on outpatient, call is until 10pm Rounds: • 8 or 9 am with team and attending Lecture: • Main lectures are in the afternoon with UH students at UH • There are also attending rounds 2‐3 days a week in the afternoon where you practice presenting to

the attending • Lectures with Dr. Packer, who is the head of the teaching at the VA Where to sleep: • Did not have to do overnight, but they have beds

Pearls of Wisdom: Dr. Armitage likes to use the phrase “total immersion” when referring to the inpatient six weeks at UH or VA, and he’s right. They throw you right into taking histories and physicals on the first day. Overall a really good experience, many people who like to teach (even a lot of random consults I called (endo, cardio, GI) would teach me.) I got some experience at procedures and got to watch procedures (caths, colonoscopies, etc.) on my patients. You can also spend time at the VA and at the Free Clinic as part of your medicine experience at UH. There is no overnight call, and at UH and the VA they want you out by around eleven. At the VA I was able to do a lot more in managing patient care‐‐at UH the residents often get orders in before you even have a chance to get on the computer. All of my residents were great‐‐ Brian Burtch and Arminda Lumapas are very laid back and like to teach. Kathy Weishaar (who will be one of the chiefs next year [2004]) is great and will bake food. Jean Park is very funny and tries to protect you from bad preceptors. UH: The teaching was good, and the whole operation runs more smoothly here, but everything is spread out and the flow of information is much more difficult. Paper charts are difficult because its hard to decipher the handwriting. The computer system (PCOSS) blows. Patients are more scattered so there’s plenty of walking. My teaching attending was Dr. Yadavalli ‐ actually runs the HIV clinic at the VA,

10

very cool guy; very sarcastic, very funny. I was on the Weisman team which is the pulmonary team. Lots of asthma, COPD type patients, but there was plenty of other cases to go around including some rare ones. VA: Excellent learning hospital. Many patients are return customers with multiple complex medical problems and may have many social/ substance abuse issues sprinkled in on top. Very relaxed atmosphere. The best part is that all of your team and patients are concentrated in one area, so it is easy to find your intern/resident/attending when you need them. There is lot of opportunity for bedside procedures, and the computer system is fantastic ‐ easy to use and has almost everything you would need including radiology. Downsides ‐ Lots of scut work like running around to drop off specimens in the lab and searching for supplies, but everyone does this including residents. Radiology is not too sophisticated and runs a little slow, as does everything else. Nothing will get done unless you personally see to it, but when stuff does get done, you know that you were the one that made it happen (this is what my chief resident says to all the interns for their first day at the VA). They actually pay you for your meals, but the problem is the cafeteria is only open a few hours a day, and never when you actually have time to grab food (not that I would recommend the food there anyway). Attendings: Dr. Armitage: (UH) rounds quickly and is very easy to work with, does not pimp, he is fond of taking the stairs to the 8th floor of Lerner tower Dr. Arafah and Dr. Beigi: (UH) were patient and instructive. Because both are endocrinologists we learned a lot about diabetes management. The AI's were the most helpful there, but that was the luck of the draw. Dr. Augustine: (VA) Young and very sharp. Good teacher. She does great teaching sessions when she has the time. She cares a lot about the patients, and has a good style. Dr. Beck: (Med/Peds UH) The cream of the crop of attendings; he expects you to know everything about your patients and he teaches a ton (during rounds, during the afternoons, whenever) Do some extra reading on your patients before you present especially if they have a clotting disorder (always ask female patients how many miscarriages and during what trimester) or rheum findings. And always cover DVT prophylaxis in your assessment/plan. Basically, try and follow him around in the afternoons if you are done with your work because he has a wealth of knowledge and loves to share it. Dr. Chandra: He is a hospitalist and is very good. Again, he was patient with us. He enjoyed teaching and was truly interested in our learning. Definitely a good guy. The entire team was good and worked efficiently. Dr. Graham: ‐ Very cool guy and seems to know just about everything. Hands‐off style, which wasn't as good for organized teaching sessions, but a great resource for any questions you might have. ID specialist. Dr. Heinzel: (VA) ID guy; nice, easy going pretty much let the team run things on its own Dr. Hirsch: (UH) Nice lady. She does TB research and spends only a few months on the wards each year. She's very efficient and knowledgeable. She let the resident run the show, but always knew what was

11

going on. Almost no pimping on rounds, but also didn't teach as much. She was very approachable however, and has some good teaching sessions. Dr. Johnson: (UH) most people on the team did not get along with him. He has a difficult personality and can ask questions that are unclear. He's very old school when he rounds and wants to know calculations for fluid and electrolyte corrections. His rounds last all morning. He also does not like to examine a patient with another person at the same time and will step back if you place the stethoscope on a patient when he's auscultating. He also will say something if you examine the patient from the left. He generally wasn't bad to me‐‐I think it's because he saw me with a lot of reference pocket books which he seems to like to see. Oh, and don't wait for him to ask you to present a patient because he will move on without giving you a chance. Dr. Miller: (UH) He is a nephrologist that loves to teach...but only about the Kidney. Basically the patient could come in with a hip fracture and he would somehow relate that to renal function or dialysis. Nice guy though with a more quiet personality. Dr. Schilz: (UH) Nice guy, rounds took 4 hours everyday whether we were admitting or not. In retrospect, it was good because he was pimping and teaching the entire time. You always had to be paying attention, and he expected a lot for the team in a very professional way. The days were very long but I learned a ton. Most important lesson: the attending and resident should NEVER know more about your patient than you do. Dr. Tomolo:(VA) Nice and gives helpful feedback, she will ask you questions but not really pimp you. Dr. Whelan: Seemed to be the quiet type but he looks like someone who could be on TV. Funny guy with a dry sense of humor. Rounds usually start at 8am‐ish. We would also have sitting rounds where we would go over all the patients in a conference room for about 30 minutes and the stop by each pt's room so he could do a brief exam. We were never done with rounds later than 10AM. He would also hold some teaching sessions in the afternoon to go over something we had seen recently and the differential Dx. Overall a good experience. Dr. (Dan) Wolpaw: (VA) Rarely seen after lunch. Rounds were at the bedside and were quick compared to other teams (done around 10:30). He is very good with his patients and would do some teaching at the bedside if there were interesting findings. We would have teaching sessions every‐other‐day before lunch where we would talk about physical exam stuff and diagnosis of diseases...he would usually provide some reading material on the topic as well as a poem. NOTES: Make sure you ask Dr. Packer to take you to the art museum to look for pathology in the art, one of the coolest things we did.

12

CCF Inpt. medicine at CCF consists of one month of general medicine and one month of cardiology.

You don't get a choice about doing something else, though maybe if you really bugged someone, they would let you. On gen med, there are 6 or 7 gen med teams, and you'll be assigned to a specific intern and resident. Each team has 1 attending, 2 seniors, and 2 interns, and the call is Q4. So every other day, one half of your team is on call, and on the opposite days, another team takes call. You always take call with the same interns/seniors. This can be a good thing or a bad thing, depending on who you get. Expect to be there until at least 1pm when you are post call. Also, call is Q4, and you have to take it Q4, you can't take it on the 'average' of Q4 or something like that like you can at Metro. Weekend call works like this: if you have call on Thursday, you get off on Friday and don't have to come back until Monday AM. If you are on call on Saturday, you have to be there on Saturday morning like it wasn't a weekend, and then you leave Sunday afternoon. You don't get Friday off or any of that nonsense. If you are on Sunday, you show up Sunday AM, leave Monday PM. This means that there will be one point where you don't get a day off for 2 weeks, but it also means that there is one weekend where you get the whole weekend off. I usually got at least 2 hours sleep on gen med. Round were usually at 7:30 or 8:00 until noon. As far as the pt.'s you see, you see a bit of everything. Cardiac, GI, ID. People think that the clinic is full of rich people, and this is kind of true, but there are a fair amount of people who come in because they smoked a little too much rock cocaine. Gen med. wasn't where I saw most of the wealthy people. Also, parking is free at CCF, and they give you meal vouchers for when you are on call. Lunch is provided by the dept. on weekdays, too.

Cardiology: you will see tons of heart failure, A fib, CAD, surgical patients, as well as weird

arrhythmias and such that has everyone else stumped. Cardiology has the same call schedule, but my calls were way more relaxed. On Cardiology, there is 1 senior and 2 interns. You always have 20 patients, and if you discharge them, you get new ones within the hour. Which is actually good, because you aren't admitting people at night, and a lot of times the intern will just let you sleep. Cardiology is where the Clinic might get a reputation for having lots of wealthy folk, because there are tons of surgical patients pre and post‐op for cardio‐thoracic surgery. A lot of these people come from other states or countries. Rounds are usually from 9:30 until 12 or 12:30, starting late because it would be hard for the intern to write 10 notes before 7:30. Location: • H80

Teams: • Kimball A/B, Tucker A/B are the 4 inpatient teams; Cardiology Teaching Service A/B are the 2 cards

inpatient services Call Schedule: • Q4, start at 7‐730am on the 4th day and leave around 12‐1pm the afternoon following for 4 weeks

on inpatient medicine, 2 weeks on cardiology; 2 weeks of outpatient medicine w/ subspecialty clinic days (eg. endocrinology, etc.)

Rounds: • Daily, usually at least until noon (with cardiology teaching service usually until at least 2pm)

13

Lecture: • Daily noon conference with free lunch, mandatory attendance by residents • Friday morning lectures require students to prepare case presentations, presentations in debate

format (point‐counterpoint), as well as faculty‐directed lectures Sleep: • There are call rooms for MS3's on Core 1 specifically Schedule: • Inpatient 7am until 5‐6‐7pm (usually more like 5pm), outpatient 8am‐5pm Pearls: • Heavy cardiology emphasis • Unique patients ‐ often get sent patients from other hospitals because the OSH cannot figure out

what's wrong • Long white coats, so nurses cannot tell whether you're a medical student or a resident • Required 4‐week written self‐evaluations Attendings: Dr. Deedy: is fast, and sees all 20 pt.'s on the service. He will take you to the cath lab probably every third day, and read echoes, EKGs, and cath film daily. You will probably see a few interventions also, though Deedy does not do them. He does not hold formal teaching sessions, but he is very approachable, and will always answer questions. Dr. Mark Mayer ‐ the director of Core 1 at CCF, great teacher and emphasis on teaching medical students, provides lots of CAS feedback, but can be long‐winded and rounds until mid‐afternoon usually Dr. Jaeber: is a specialist in Echo and also Nuclear Imaging. He will stop to remind you about the social aspects of medicine often. He also meets in the afternoon, shows lots of cath film, echo, EKG, as well as nuclear imaging. I think I saw less caths with him, as he does not do them. He does not hold formal teaching sessions either, but he is eager to answer questions and will always stop and talk if there is a good teaching point. He is very laid back, and it will be a fun service should you be lucky enough to get him.

Outpatient Medicine: the big difference between here and UH, Metro is that you are with the

same person, or at least office, for the whole time. Which could be a blessing or a curse. I had Dr. Bal in Beachwood, and he was excellent. Very laid back, loves to chat, loves to teach about both the science of medicine and the subtleties of interacting with people. Will address depression, family problems, etc.

14

St. Vincent’s Positives: Unique patient population; most patients are the classic “underserved,” they are the un/underinsured, poor, elderly. Consequently, they tend to present to hospital or clinic with disease at a later state than in other hospitals. Ethically, not really a positive, but interesting for teaching purposes. Also, there are many patients that abuse substances; for instance the cocaine induced cardiac ischemia is very common diagnosis there.

Teaching is good. There are many scheduled opportunities for learning throughout the week. There are attending rounds with teaching three times a week. Also, there is scheduled meetings with the clerkship director (Elueze) once a week. Additionally, there is scheduled teaching with the chief medical resident once a week. At these sessions, we reviewed physical exam by systems, reviewed H&P, and began to do assessment and plans with patients that we identify on our teams. Also, with Dr. Elueze we reviewed the most common medical conditions to present ie. HTN, DM, altered mental status, and reviewed the pertinent histories, exam findings, studies and work up necessary for these patients. Of course we had to present to him our own patients… as does everyone I think. Finally the last two weeks, we met and did focused exercises to prepare for the OSCE, including common histories/ differentials (eg. For headache), and exams that were timed to adjust for the limited time at the actual exam. We also had weekly cardiology sessions with a cardiologist to see some common procedures (cardiac cath), review EKGs, ECHOs inc (TTE/TEE), and common cardiac dz with manifestations and management.

I thought it was great that like 98% of the docs were foreign because it allowed me to become exposed to different cultures and ways of thinking (eg. Lecture given by two residents on death and dying from muslim and hindu perspectives… and the end of davali festival put on by medical residents that included foods, dress, and traditional Indian dance and song). They really are like a family and very welcoming to the students. Also the residency director Dr. Christie is awesome.

Pretty much all of the staff is interested in teaching and because the hospital is relatively small, you have a lot more access to people than I would think in other places. Also cause they only take 2‐4 students at a time, there are a lot more seniors available for teaching if interested. Negatives: weekly communication skills sessions that some would call a positive but is really a lot like ICM for the numerous foreign grads to acclimate themselves, perhaps, to the typical way things are done in the US. I found these sessions fun, but the other students didn’t like it; includes role‐playing and touchy feely feelings stuff. We were supposed to have radiology sessions but that didn’t pan out. However, endo sessions are available with the staff endocrinologist. We were also hooked up with a mentor attending to do whatever we wished, be it H&P, questions, assessments and plans…. Or just release tension. • On call: Q4 with team – we get our own private call room and they provide meal tickets for dinner

and breakfast. • Parking is free in lot near the hospital. • Lunch provided everyday at noon conference. • Students required to carry pt load of 2‐3 patients at any time follow their care etc, typically we have

to present on one topic for attending rounds also.

15

Surgery Resources: • Surgical Recall (a MUST for this rotation! key to keep in your pocket and review before cases – it has

virtually every pimp question you will get, great for last minute reference before going into the OR; Surgery‐‐portions written by Metro attendings and residents, very useful for the oral exam, That being said, this is NOT a substitute for reading the source material, as this is rather light on that)

• Mann’s Surgery: A Competency‐Based Companion ‐‐ this textbook is "required" by Metro & is extremely useful in preparing for your oral exam, as well as reading up on surgeries the night before. This is recommended by Dr. Persons from UH and is extremely helpful in getting you to think about how to work‐up basic surgical cases. It is a great help for your oral exam

• Washington Manual of Surgery • Sabiston’s Textbook of Surgery is available on MDConsult. • NMS surgery • Pestana surgery review PDF that circulates (basically = Kaplan surgery review, same author) • Surgery Case Files ‐ great book especially with preparation for oral exams • Blueprints in Surgery—very basic review, ok for shelf review • Lawrence Essentials of General Surgery—required; more detailed, but if you want to go into a

surgical field and want to look good, this is a great resource—good detailed book for shelf • Schwartz’s Surgery – it’s on Access medicine and therefore free, it has basically the same thing as

Lawrence, I recommend saving your money and using this • Pre‐Test in Surgery—good review before shelf, keep in mind there are usually 2‐3 question on the

shelf on gyn surgery which I don’t believe is covered by this book or any other review source I have found. Yes, it is a bunch of BS, but what can you do

Tools in your pocket: • Trauma shears/ scissors to remove dressings • Tape • Sterile sponges (gauze pads) to put new dressings on • Surgical Recall—good quick reference to have on hand before a case • Suture—it is always good to have some extra around to keep practicing your knot tying when there

is down time. Ask at the end of a case for extras

Metro Overview: • 4 weeks on General Surgery • 2 different 2 week “electives with specialty teams (plastics, ortho, vascular) • Trauma call throughout

Location: • 8B/C for General Surgery • 7B green team, 7A blue team • Wards 8B, 5A, 5C and OR on ground floor

16

Teams: • For General Surgery: Blue Team (general surgery and breast) or Green Team (general surgery and

endocrine) • For 2‐week electives: Vascular Surgery, ENT, Urology, Ortho, Burns, Orthopedics, Trauma, Critical

Care, Cardiothoracic, Plastics • 2‐3 medstudents, 2 interns, 1 senior, 1 sub‐senior, 3‐4 attendings Call Schedule: • Trauma call, approx Q4‐5 • 1x/week with the trauma surgery team: you have a pager and respond to all the trauma calls with

them, otherwise you can sleep Rounds: • 6am; usually med students arrive 5‐5:30 to help with prerounds • 6a‐7a, pre‐round and write notes on your patients beforehand (team dependent on whether they

want you to round on patients or just collect vitals) Lecture: • Core 1 lecture Wednesdays 8‐12am • 7a surgery conferences 2‐3x/wk • Green team has Friday med student presentations on an interesting case 1x/wk that you (and all the

other students) will be pimped on Where to Sleep: • In the surgery call room on the 8th floor Typical Schedule: • 5‐5:30am arrive to preround • 6‐7:30am rounds • 7‐8am maybe a conference with all the surgeons • 7:30am surgeries begin. Scrub in to ~3 operations, see consults in between, round at the end of the

day with the senior • Depending on the surgery load for the day & who your chief resident is, you may be dismissed to go

home anywhere from 4‐7pm, or occasionally later if you go into a late, long surgery. • On General Surgery, there is 1/2 day/week of Resident clinic or clinic with an Attending, plus an

additional half day if you're on Blue Surgery Team for breast clinic • Once/week there is M&M and once/week there is Conference for your team, where the med

students present a case & discuss with the Attendings & Residents. (both occur in the morning, before surgeries begin) Surgery Grand Rounds Thursdays 4pm.

Pearls of Wisdom: • Always carry food in your pockets to nibble on between surgeries. • I personally think the whole advice about carrying around Surgical Recall & ducking into the

bathroom to review it before scrubbing in to cases is unnecessary. You almost always know the day before what surgeries you'll be going into, and so you can read up on them the night before. Also, in terms of "pimping" in the OR, it is often more important to know the history of the patient than to know all the details about the surgery.

17

• Look at the OR schedule online the day before to study up for the cases you'll be going into, pay attention in the OR as much as you can even if it gets really boring, only ask intelligent questions whose answers can't easily be looked up, review in Surgical Recall any free minute, work WELL with the other med students on your team

Attendings: General Surgery: Less intense work‐load at the beginning of the year, still plenty to do. Dr. Malangoni: President of American Counsel of Surgeons (or something cool like that). Chair of surgery. Friendly, has tons of information, tends to pimp the residents harder than the students. Dr. Brandt: Does your final grade, soft‐spoken and loves to ask you what you think about things. Will ask a lot of questions especially about indications for surgery and differentials and prevalence and everything else. When he asks you to look something up he doesn't forget so you should probably remember too. When he asks a question he is trying to help you learn, not pimping. Really think about your answer. He will ask follow‐up questions like “are you sure?” If you are, say yes, he’s just seeing how much you know. Know your patient, asks a lot of questions in the OR, believer of the Socratic method (rarely gives you any answers), talks quietly so listen carefully, hates extraneous noises in the OR (including the bear hugger), clearly cares a lot about medstudents and is happy to answer intelligent questions at appropriate times during the case. Dr. McHenry: "You're killin me!" Great doc to work with high energy. Overall doesn't pimp too much but he will ask anatomy questions as well as some questions about incidence and indications. Blue Team: BLUE TEAM: Make sure you learn how to cut sutures early. Does a lot of endocrine surgery, likes to ask about anatomy and embryology in the neck, lets a lot of people scrub into all of his cases and hold things (lots of hands in the field), can get a bit fired up when things go wrong during the operation but all is always forgotten and back to jokes once everything is closed. Dr. Gagliardi: He's very intense, and high paced, can make you feel like crap and may enjoy doing so. But if you are somewhat aggressive and ask decent questions he may teach you something, and may let you do things. When you drive the camera make sure you are paying attention to everything he says and for god sake's "go in" when he says go in and DON'T rotate the camera. Have some idea of the anatomy before going in. Dr. Averbook: He's somewhat pleasant, but don't contaminate anything he hates that. He's also meticulous in the OR and may not let you do much. He will also expect you prepared for the case and ask you questions about the surgery and anatomy so read ahead for him. Does a lot of melanoma surgeries and other skin surgeries. Very meticulous and therefore doesn’t let you do a lot in the OR. Dr. Cha ‐ really really nice guy, more apt to ask you about who is playing on his ipod than pimp you about the case. Very willing to answer any questions you have. Impressive laproscopic work. Dr. Priebe ‐‐ mostly colorectal. He is the one Gen Surg attending whom some residents are scared of, but as long as you act confident with him, he won't give you a hard time. Dr. Joseph ‐‐ does a bit of everything. Very nice. Dr. Stevenson: Very nice, ask questions. Doesn't really ask you anything. Does mostly breast surgery. Doesn’t ask a lot of questions in the OR.

18

Dr. Fallon: Avoid his gastric bypasses at all costs because you will be retracting 400lbs for several hours. Read ahead for him as well. Also head of Trauma. Good teacher but usually not full of smiles. Pay attention while he is lecturing mostly because its stuff you need to know and also because you'll get in trouble for talking. Dr. Mansour: Great guy, good to work with. Prepare a little. Make sure you try and talk to the patient and get the patient's history beforehand, he expects you know about the patient. METRO specialties: Trauma: Trauma service is very exciting but you are rarely in the OR. Expect to work hard when you are on call, and in the trauma bay you will do a lot of rectals, Foleys and pulling for X‐rays. You get to see a ton of interesting things though. Being on call with the Trauma team is an exciting night of call. Don’t be afraid to jump in with the trauma patients and help out where you can. Burns/Peds: The service is much busier while combined and the residents are not always happy about that. But the cases are amazing although the OR is very warm for both. Dr. Yowler: Very blunt, matter‐of‐fact, and often funny doc to work with. Laughs a lot and will let you do cool stuff in the OR i.e. stapling, skin‐meshing. Dr. Stallion: Likes to teach but is very very busy. He will schedule himself to work all day so expect to do the same. Doesn't ask questions in the OR but he will give you a piece of paper and a sterile marking pen at the beginning of a case and ask you to write everything you know about the case or draw the pertinent anatomy. Its not as bad as it sounds though and its a great review of the scope of a subject. Vascular: overall busy busy service, expect do stay late and do work, but also learn quite a bit. Make sure you know how to use the sucker. Dr. Moawad: Nice guy, will let you do things in the OR if you can prove you know what you are doing, ask questions he will teach. Dr. Alexander: queit, mild mannered. Very Nice. He will let you do ALOT. When you have to prepare a patient for Friday conference, be very thorough and very precise. Don’t say anything you don’t mean, word for word. Dr. Alexander will grill you. Know the background of any studies you cite, and know the logic and specifics behind your patient’s work‐up, even if it seems like an obvious case. Plastics: all case grads, good guys. Didn't work with Dr. Jordan, but Dr. Bernard and Kaufman have more relaxed OR's then some other surgeons, they will talk to you about anything. But ask questions and they will teach, they'll let you do stuff too.

19

UH Overview: • The schedule is split with half of the time on a general surgery team, and the second half split

between Anesthesia, Vascular surgery, and an elective. Location: • Lakeside 9th floor administration, patients in Lerner tower, OR in Lerner tower 2 Call schedule: • One day a week until 11pm and one overnight during the 8 weeks. Lecture: • Anytime, any day during the weekday (usually in the afternoon, but can be at any time) Where to sleep: • Med student call rooms on Lakeside 3 (but there are not always enough beds—so get there early

and claim a room!) with the new schedule, since you are only overnight one night, I recommend staying up so you don’t miss anything

Typical Schedule: • Morning rounds start at 6 am for Gold. Preround 5:20‐5:30am. OR in the morning.

Pearls of Wisdom: • When you take call, make sure you page the intern or resident on night float. Preferably follow

them around otherwise you may never hear from them again. • Some upsides about being at UH were that I saw a huge range of surgeries, covering most of the

basic areas of the exam. One down side is that there is virtually no trauma at UH, and the shelf is trauma heavy. Also the medical record system and order system (PCOSS) are a nightmare, but fortunately they probably won’t have you dealing too much with it. They are also a pain in the ass about parking, so be prepared to pay or otherwise you will be parking in the boonies (honestly the Waldorf is closer than the free parking).

• Some general Advice about surgery: o Surgery is tough no matter where you go. There are expectations that you need to know

stuff even when no one has told you what it is and you have no idea how to do it. Just do the best you can, and try to take the initiative for helping out the team whenever possible. Usually this means changing dressings, pre‐rounding on patients if you have pre‐rounds, getting charts. Surgery is very stressful for the residents and the more stuff you do for them the more time they have to teach you. One good piece of advice is to never take anything personally, because 99% it isn’t. Try to read 30 minutes every day, read surgical recall before you go into cases, it will help you with pimping. People forget that pimping is not meant to make you feel like an idiot, it is a way to teach you, and often the question get harder because they want to find at what level they should be teaching you. This is coming straight from the attendings. That being said, know your anatomy.

Attendings: General Surgery:

20

GOLD Surgery: mainly GI, Colorectal surgery Dr. Harry Reynolds (preceptor): He's a good guy, but very strict in the OR. Make sure you give the guy good lighting. Be ready to retract like you are a water skier. He mostly does Colorectal surg. Dr. Stellato(preceptor)‐ Bariatric surgery guy. Lots of Roux en Y Gastric Bypasses. May appear to be a hardass, but he's a good guy. Excellent teacher. Your differential on the pimping in the OR: Its either Ligament of Treitz or Falciform Ligament. Dr. Hallowell‐ Funny guy. Good teacher. Let's you do stuff. Jokingly threatened to come after me if there was a leak following my horrible knots. Bariatric surgery guy. Stellato's accomplice in Gastric Bypass. Dr. Zollinger (preceptor)‐ The son of the guy who discovered the Gastrinoma. Not Dr. Ellison. But the other guy. He is demanding. He'll make you choose the next most pertinent diagnostic study in a workup. So don't regurgitate out everything you just read in Recall. A lot of retracting. The resident may let you suture when he leaves. He does a lot of Herniorraphy and Breast biopsies. Silver Surgery: mostly outpatient surgeries; Silver people seemed to have a little more time to teach. Dr. Wilhelm: he's a nice guy Dr. Onders: Laparoscopic guy who cranks out the surgeries in like 20 min. He did some diaphragm surgery on former superman, Christopher Reeve. Funny dude. Will probably pimp you on Hasselbeck's Triangle. Dr. Shuck: Thyroidectomies. Parathyroidectomies. Good guy. Pimps you on the recurrent laryngeal nerve, hoarseness, complications. Platysma. Dr. Persons (preceptor): She runs the UH surgery rotation. She might seem gruff at the beginning, but she is actually very cool. In the OR, she'll ask you about the patient. Know the patient. Check. Know the pathology. Read that Breast section in recall a billion times. Know about sentinel node stuff, etc. Dr. Leeming: Does a lot of novel breast oncologic surgeries, less aggressive than some of the other surgeons SICU: Dr. Norcia: Dr. Rowbottom: Dr. Fitzpatrick: good teacher. sympathizes with your plight. Urology Elective: Dr. Goldman: very cool guy to hang out with in the OR and in clinic. Mostly does Female urogenital surgery. Dr. Bodner: ESWL Dr. Lee Ponsky Dr. Cherrulo – new Vascular Surgery: Overall great group of teachers, but has a different schedule than the general surgeons. Lots of emphasis on teaching (every day has teaching rounds). Most of the rarely swear at all, and rarely get

21

upset at residents or nurses. I would honestly try to get in on the open cases just because there isn’t much to do on the endovascular ones. Dr. Goldstone: Will let you practice suturing left over Dacron from grafts if you ask Dr. Blebea: Head of the department Dr. Baele: Nice guy, but if you ask or say something, be prepared to be pimped about it Dr. Wong: Does a lot of endovascular stenting Dr. Wang: Newcomer to team, probably one of the most calm surgeons I have ever seen Transplant: Dr. Schulak: Dr. Aeder: Cardiac (there is no team rounding with them, but a lot of students shadow these guys, so you might want to take a look) Dr. Markowitz: Will show you a great deal if you show interest, he does mostly valves Dr. Cobanoglu: Head of the department, make sure you know your history of surgery (especially CT), because he will pimp you on this. He really wants to get students involved with the department Dr. Garcia: Transplant guy, very nice although I didn’t get to see any transplants Dr. Blitz: Very research oriented, often does very difficult, novel cases, but often has a lot of people in his room like students, specializes in Ventricular Assistant Devices. Thoracic: Dr. Robke: Will let you do stuff if you express interest ENT: Dr. Magerian: Specializes in otology Dr. Diane Ponsky Peds: Dr. Todd Ponsky: If you show an interest, he may let you do stuff Dr. Ungerleider: Pediatric cardiothoracic, unlike adult there is a team rotating with him, you probably won’t get to do anything, but there are nice monitors to see everything with if you are interested Plastics: Dr. Soltanian: Other general surgeons: Dr. Rosen: Hernias, know hesselbach’s triangle (sp?) Dr. Hardacre: Pancreas, very upbeat and passionate Dr. Siegal: Hepatobiliary Nurses: Rita: Make sure you know how to scrub in on your first surgery. And don't fall for any devious tricks designed to make you contaminate yourself or the field. If you do, you will pay the dear price of complete and utter humiliation.

22

CCF Location • H50, M, surgical suites Teams • General surgery, endocrine surgery, colorectal surgery, vascular surgery Call Schedule • 3‐4 times over 6 weeks, all on weekend (either weekend day or night), 12‐hour • No accountability for attending call or staying for the whole night Rounds • First thing in the morning, sometimes at 5:30am, for about 1 hour at most Lecture • Same as medicine for Friday morning, also morning conference 1 day per week at 7am Where to Sleep • Share call rooms with medicine people Typical Schedule • 5am ‐ 7pm Pearls of Wisdom • If you are not interested in surgery, you do not have to stay for call: show‐up for a few hours until all

the new patient consults/admissions have come in, then ask to leave for a while ‐ the resident/intern will never page you

Attendings Tracy Hull: colorectal, best surgical experience, aggressive and makes you work long hours and wants things done exactly her way, but will let you do a lot in the OR (incisions, suture, tie knots, bovie, including in loops of bowel), wants you to be aggressive. Remember it's her way or the highway, and you will do fine. Dr. Hull will let you do as much as you want in the OR. FIRST day she'll let you make the opening incision, bovi, etc. Dr. Hull also really likes it when you're proactive in the OR. If the light isn't in the right place, reach up and move it (some other attendings don't let you touch anything). She also likes to teach, which is nice. Pimping is pretty minimal. One thing you have to watch out for though is that she is a very intense. Just don't take it personally and you'll be ok.

23

VA Location: • Second floor of VA Teams: • 4 weeks of general surgery (1 senior, 1 junior, 1 intern), 2 weeks vascular (1 senior, 1 junior, 1

intern), 2 weeks elective—usually anesthesia or ICU Call schedule: • q4 during gen surg and vascular Rounds: • 6:30 or 7:00 AM with senior resident Lecture: • With UH group Where to sleep: • Med student call room/ share intern call room on the floor Pearls of Wisdom: • From what I hear now, there are really only 2 options at the VA, vascular surgery and general

surgery, and it is basically split 50/50. You can do an elective if you ask, but keep this in mind when considering going there.

• Class of 2005 comments: o We didn't have as much exposure to the attending except during conferences and weekly

rounds. Nobody was malignant – they were all pretty nice. o None of the general surgery attendings pimped. The vascular attendings (Jean‐Claude and

Pinault) were more serious than the general surgery attendings (more likely to pimp.) They were nice and student‐friendly, they just had a different style with more pimping. The schedule in vascular and general medicine consisted pretty much of preround early enough to get vitals and notes on all your patients before rounds (which started around 6 or 6:30, depends on your team). Get to know your intern and be assertive trying to learn skills ‐ they will be very busy trying to get everything done, so the more you help the team, the more they will be willing to teach you.

24

OB/GYN Resources: • I found the “required” textbook to be very useful: Hacker & Moore’s Essentials of Obstetrics and

Gynecology. • Remember Williams Obstetrics & Williams Gynecology are both available through AccessMedicine. • PreTest is okay, but not as good for OB as it is for other subjects. • Blueprints in OB/GYN—good for basic review and questions • NMS OB/GYN—hard to get through but has lots of info • First Aid for OB/Gyn—concise info and good material on working up common issues you will see on

the wards Tools in your pocket: • Tape measure • Packets of surgi‐lube • Pregnancy wheel (to help you quickly determine how many weeks gestation and/ or the patients

due date IF they are certain of their last menstrual period) – if you are at UH, this is provided for you.

Metro Overview: • 4 weeks OB/GYN: 2 weeks gyn surgery, 1 week OB Labor & Delivery days, 1 week OB Labor &

Delivery nights Location: • Labor & Delivery is on 2nd floor near the C elevators • Gyn surg is based on 8C • Continuity clinic is in the outpatient pavilion on the 2nd floor, across the atrium from the café. • Surgery is on the 1st floor, past the C elevators to the right through a set of double doors. Teams:

• Labor & Delivery has a day team and a night float team. • Day team consists of a 4th year, 3rd year, 2nd year, 1st year, plus, variably, med students, an ED

resident, and a Family Medicine resident. • Night float team consists of a 4th year, a 3rd year, and a 1st year, plus med student(s). Gyn

surgery has 2 residents – a 4th year and a 2nd year. • In the outpatient part, you will be working one on one with an attending one half day per week

and in the resident clinic one half day. • For surgery, you will be working with 1‐2 residents and possibly another medical student. You

can go in any of the surgeries you want, but split them with the other med student. In the OR it is generally 1 attending, 1 resident/PA and you.

• On L&D, the number of med students partly depends on if there is a 4th year rotating there. Otherwise, there are generally 3 interns: OB, Family and ED. Then a second year and a third or fourth year. Attendings have a rotating schedule, though there is always a high risk and a regular OB on during the day and one attending on at night.

25

Call Schedule: • 1 weekend Friday night + all day Sunday; 1 weekend 24 hours Sat‐Sun • You will have no call during outpatient. On inpatient you will have weekend calls: one Friday night

(6pm‐9am) and Sunday (9am‐5pm), one Saturday‐Sunday (9am‐9am), and one weekend when you start night float (Sunday at 5pm).

Rounds: • On L&D, rounds occur at the beginning & end of the shift. Held in the conference room on L&D,

where every patient's name is written on a big board. Students are not responsible for presenting patients on rounds. Rounding on gyn surg is a little more informal, since there are only 2 residents – they usually decide the night before when to round, based on how many patients they have to see. You can definitely preround & report on patients whose surgeries you saw.

• You will round on any patient you saw in surgery or were present/participated in the delivery. On call, you will generally help the intern round on all the delivered patients for the two hours prior to shift change. On L&D, you only round on the patients you delivered, but otherwise should be present in the morning at 6am when the interns are rounds because you are first up to deliver during that time. At 8am on weekdays, “Board rounds” occur, which is the shift change from night team to day team. You will not be expected to present patients, though at times you may be pimped.

Lecture: • Wednesdays at 12 or 1pm, lasts 3‐4 hours. Where to Sleep: • There is a call room down the hallway from L&D, but you rarely have a chance to sleep • Med student call room is across from L&D, S229. They will give you the code. This is also a good

place to sleep when on NICU call during peds. Typical Schedule: • Gyn Surg: 6/6:30am rounds with the team, 7:30 surgeries begin

o You may help with post‐op checks in the afternoon. Usually done by 5‐6pm. o Often depends on your resident. Typically, be ready in pre‐op area at 7am, which means if

you had anyone to round on you should be done by then. You will then stay as long as surgeries are running, unless you are told you can go home. Generally that is 4‐7pm.

• L&D days: 6am‐6pm M‐Th; 6am‐noon Fri o Arrive at 6am, interns will be rounding. Board rounds at 8am and 6pm

• L&D nights: 5pm‐7am Sun‐Wed; 5pm‐11pm Th. They may send you home early, since 6‐7am is "rounds" which are not very informative for students going off‐shift.

o Arrive at 6pm for Board Rounds. Leave either at 6am, earlier if your residents tell you you can leave.

Pearls of Wisdom:

• On Labor & Delivery, med students can see patients in triage, and in addition, are supposed to follow at least 1 patient/day who is actually there to deliver – do cervical checks, be present when it’s time to push & get hands‐on time during delivery. While this is the expectation from the clerkship director, things are more complicated in reality. During the day, the intern and any rotators from other services (EM, FM) are basically your "competition" in terms of whether you

26

get to deliver any babies for the day. Be really persistent about putting your name next to a particular patient on the big white board in the conference room, and make sure you are actively following the patient ‐‐ checking on how she's doing, hounding the resident to be present when they do cervical checks Q2 hrs, etc. If you're not on your toes, the resident will just go in there to do the cervical check without you. You can also help the patient "push" which usually goes on for quite a while before the delivery actually occurs (if you're not helping the patient push, it is typically the nurses' job.) The best way to make sure you get experience with deliveries is to find the patients on the board who are listed as "private" which means an attending will be delivering the baby, not a resident. Ask the attending politely at the beginning of your shift if s/he would be willing to let you participate in the delivery. S/he will almost always then introduce you to the patient and actually let you deliver the baby. But you should still try to be persistent about checking on the patient while she's in labor. It's generally easier to follow patients when you are on night float, because there are fewer residents on the team. At night you also have the opportunity to go see patients in the ED, and go into surgeries.

• This seems to be a rotation where people either love it or they hate it, and attending can tell. If you hate it, try to at least be interested for the time you are there. If you ask questions, are willing to learn, and can answer pimp questions, it goes a long way towards setting up a good relationship with these attendings. The residents can be a bit stand‐offish, but don’t let it stop you from asking questions and hanging around them so that they know you want in when there is action. Don’t be obnoxious asking to help, but make sure they know early you want to be present.

• Even if you have already met an attending, make sure to introduce yourself again. Often you can jog their memory, or at least they will pretend to remember. Often gives you more freedom.

• Be friendly with the nurses. The OR nurses can really help you, and will, especially if you help them. Help get the patient set up in the room, ask the scrub nurse if she has an extra gown for you. If she doesn’t, go get one and get your own gloves. Van tends to be the scrub nurse in the benign Gyn cases. If she has time, and you ask, she will go over instruments with you.

• PRACTICE KNOT TYING. It goes a long way toward being included in surgery and repairing episiotomies if when the attending asks “can you tie?” and you can emphatically answer “yes.” Carrying around suture tied to your nametag is not a bad idea.

• This shelf exam was one of the harder ones. Make sure you keep trying to read or do questions in your down time on L&D. Try to read while on the surgery part.

Attendings: There’s a different attending every day & every night on L&D, and you may only see a given attending once or twice in the OR, so be sure to send a request for CAS eval once you’ve had a single interaction with a particular attending. Dr. Stetzer is always willing to teach, and fancies himself a great liaison with med students. He will pimp you like none other and will answer your questions to the fullest, though he might turn around and tell you to look it up. However, he might also make you feel inadequate. Try not to take it personally, he does it to everyone. If you can get past that, he is a great teacher. Dr. Pollard is GREAT. He will answer questions you put to him and is willing to sit down and teach if he has time.

27

Dr. Kitagawa is amazing. If you speak Spanish, you may want to request to be in his outpatient clinic. He is fun to be around and is always willing to teach. Dr. Edelmen can be a bit of a jerk. However, he fancies himself good with medical students, so if you ask questions and act interested it can go a long way toward putting yourself in his good graces. He does not tend to fill out CAS feedback.

UH Location: • MacDonald Women’s Hospital Teams: • OB‐GYN Rotation

o 1 week of L&D which will be night float (supposed to be 7pm‐7am, but since there are daily lectures in the evening and you stay for rounds in the morning, it’s more like 4:00pm – 7:30am) there is no longer L&D time during the day‐ assist in deliveries and follow ante‐partum patients

o 1 week gyn onc ‐ follow onc patients in OR and on floor o 2 weeks outpatient ob/gyn clinic (some patients are in the Women’s Health Clinic (WHC)

which is in the Rainbow part of UH, but since they can take only 2 students at a time, others go to private practice clinics which can be anywhere from Landerbrook to Westlake)

• ELECTIVE Ob‐Gyn/ Peds Rotation o 1 week newborn nursery o 2 weeks of a peds or ob elective (peds gi, neuro, derm, reproductive endocrine (REI),

preterm, ultrasound, etc o 1 week of Maternal Fetal Medicine (basically ultrasound, genetics, etc) changed as of 2/1/10

• NOTE: These rotation schedules have all just changed, starting after my group finishes in March 2010. I’m not sure how many weeks are spent on which service on the new schedule.

Call schedule: • 4‐5 calls/ month, no call during nursery and outpatient time, gyn call only until 11 PM

Rounds: • L&D starts at 7 am SHARP in the conference room on MAC 2, arrive early, gyn surg rounds at 6 or 7

am, gyn‐onc you pre‐round at 5:30am and rounds with the attending are different every day, outpatient begins at 9 am, but arrive at 8:30 am at the latest – in the WHC, the nurses run the show – for that two weeks, only you and them will be there all day, every day – residents are different am and pm daily. Make the most of this and GET TO KNOW YOUR NURSES they will save you (additionally, please apply this concept to every service and every rotation)

Lecture: • 4‐6 most days, very relaxed but if you are late you will be paged ‐ covers a lot of stuff for the exam

that you might not see during your rotation. FRIDAY – you must be at grand rounds which start at 7:30 am in the conference room on MAC 7, you are there up until IQ+, but often there’s free lunch at noon!

28

Where to sleep: • Med student call rooms on Lakeside 4, but must share with other med students • Our call room is right by the scrub machine in Humphrey 2, just down the hall from L&D – door code

is 12345#. However, generally sleeping is not EVER recommended. And don’t EVER tell someone “oh just page me when she’s delivering and I’ll come down” that’s not how it works, you’ll miss the delivery, and everyone will think you’re a jerk. Then the residents vent to the other medical students, like me, about you – not helpful to your evaluation.

Pearls of Wisdom:

• Shockingly a lot of fun but hours can be long. Residents are on the whole fantastic and will teach you if you display the slightest interest (which generally means breathing). Will let you close, deliver babies, perform exams, etc. Attendings are fine, I cannot for the life of me remember most of them although they were present, just different every day ‐‐ they were very benign.

• Some extra work tossed in (be sure to do your case study as soon as possible), have to write up a few H&P's on GYN for the attending, you will write every day in OB as you work triage.

• When you are on L&D introduce yourself to all the midwives and ask if you can meet their patients. For the most part, they really like med students and will let you do a TON.

CCF Teams: • Gyn onc surgery; general gyn surgery; laparoscopic gyn surgery Call Schedule: • During L&D on short call, long call, off schedule (on 7am‐7pm, then 7 am to 7 am, then have day off) • During Gyn on q 4‐5 Rounds: • No rounds on L&D, gyn rounds depend on the specialty surgery you do ‐ approximately 6:30 or 7 am

(may be expected to pre‐round before this) and then done by 7:30 to go to OR, may round again in evenings and some attendings expect you to come back after lecture to round

Lecture: see UH lecture schedule– you are expected to attend those lectures Things have changed since I did my rotation. They have gone back to the block system of 2‐3 weeks at a time with Friday lectures (CCF only) and once a week of outpatient clinic. Going back to the block system is much better in the minds of all the med students I rotated with and most of the faculty. This was my major complaint for the clinic, no continuity and no accountability. The worst was labor and delivery, were there was little direction and desire to have students participate. Take initiative when on labor and delivery and when it comes to deliveries, hang out in the hall if you want action. Every day was a 30 minute one‐upmanship medical student pimp session held by the main maternal fetal med guy (not Emery); these got pretty ugly at times. The worst were Dr. Vogel and Dr. Sole. Both are knowledgeable but seem unapproachable, perhaps Dr. Sole more than the others. Dr. Emery was excellent for maternal fetal medicine very involved in patient care, excellent teacher, good since of humor. Problems with labor and delivery: Kaiser docs and nurse practitioners often deliver patients on there own. You are not

29

allowed to work with Kaiser docs officially, but if you ask they may be willing. Nurse practioners are usually willing to work with med students if you are nice. The nurses on labor and delivery had the most attitude of any I worked with, on par with surgery; very territorial, very sensitive to hierarchy, don't pop an attitude because they will call you out to an attending without a thought. My gyn‐onc experience was pretty good. Great attending great teachers world renowned docs Dr. Bellinson and a great fellow Br. Mitchner. Dr. Uyar very nice fellow when you first meet her but when under stress can get very curt and overcritical. Gyn: the residents I worked with were pretty cool. watch out for some of the gyn reconstuctive/urogyn fellows, one big guy is an jerk. Most attendings are cool. There are a lot of benign gyn attendings so just introduce yourself immediately to whomever you’re working with. Don’t complain in public about doing another boring vaginal hysterectomy where you can’t assist or see anything. Outpatient: Great teacher Dr. Bloomfield in Solon and Dr. Gidwani at Women’s Health at a building. Two superb teachers and physicians.

Pediatrics Resources: • The Harriet Lane Handbook & Nelson Textbook of Pediatrics are both available on MDConsult.

(Harriet Lane Handbook ‐ useful info re: vitals for kids, drug doses, etc, don’t need to buy because there are usually a few around in the team rooms)

• Pediatrics Current Clinical Strategies medical book (pocket) • Blueprints (especially good for this subject, good basic review, but misses some important topics—

make sure to pay attention in lecture if this is the only source you use) • Pretest ‐ especially good for this subject, a little harder than Appleton • Swartz Pediatrics is a great reference book. It will fit in your pocket, but it is a little heavy. You will

be assigned CLIP cases, which are online cases to work through. Pay attention to these, they are a great study tool.

• I used BRS pediatrics and it was VERY long (600 pages!) It was helpful, but I didn't even come close to finishing it.

• I used UpToDate for looking up info about the patients I was following. • Appleton and Lange—good question book for shelf. • Pediatrics in Review – a great online resource with short & sweet articles on almost every topic Tools in your pocket: • Stickers or some kind of very little toy to keep kids entertained while you are examining them

30

Metro Overview: • 4 weeks Peds inpatient: 2 weeks on general peds floor, 1 week on PICU, 1 week with schedule of:

Monday‐Tuesday 30 hours (overnight) in NICU, then Wed‐Fri in Nursery Location: • Floor 4 is the regular peds floor and PICU. NICU is on floor 2. • PICU and resident break room is 4th floor between B and C elevator. NICU is between the B and C

elevators. There is nursery in both 4B and 4C. Inpatient is 4B and 4C. To get to the pediatrics conference room, go up C elevator and across there is a door that says “pediatrics.” Walk down the hall and across from a windowed in office area is the conference room. Outpatient peds is in the outpatient pavilion, first floor, across from the ED. Rapid access and well‐child are next to each other, so just ask someone to point the way.

Teams: • There are 2 teams on the regular peds floor. Usually one team is for "general pediatrics" and the

other is "comp care" (which means kids with chronic problems such as CP), but sometimes there is only 1 attending covering both teams, so everyone ends up rounding together.

• PICU will have 1 attending, 1 peds resident and 1 ER resident. • Inpatient, you will have 1 attending, 1 3rd year, 1, intern, but at rounds the team signing out is

usually there. • NICU will be one attending, two residents, and you. • Nursery you will be one on one with Dr. Swarup. • Inpatient will have 1 attending, 2‐3 residents, and you. There is a comp care team and a non‐ comp

care team. You will have a week with each. • Outpatient you will work either with residents or attending. Generally you will start out seeing

patients with a resident, then start seeing them on your own and either present to a resident or directly to an attending.

Call Schedule: • They say it's supposed to be Q4, but it's difficult to schedule since you have required didactics

Wednesday and Friday afternoons, which means you can't take call Tuesday or Thursday. Many students end up simply doing 1 call/week ‐‐ the residents don't care & no one is keeping track. There is one built‐in call, the Monday‐Tuesday that you are in the NICU.

• PICU you will be expected to take 1 call the whole week. • NICU you are only on for 1 day and 1 night. This is in the same week as newborn nursery, which has

no call. • Inpatient you will be expected to take 1 call per week. Sometimes they will enforce q4 call, but that

didn’t happen during my rotation. Rounds: • Usually start around 7am. Different attendings will do it differently: some like to round in front of

the patients' rooms; others like to do the whole thing in a conference room. • PICU rounds will depend on your attending, though generally starts at 7am. • NICU rounds start at 7am on weekdays. Nursery rounds start around 9am, after morning report. • For Inpatient will depend on your team, though generally starts at 7am.

31

Lecture: • Morning report is at 8:30 every day. There is also a noon conference. • Wednesday 12‐1pm afternoon lecture. Where to Sleep: • There are lots of med student call rooms, but unless you really think your resident will page you it

works to just sleep on the couch in the resident break room. Other places to sleep are 1101E, 901G, 601B. Ask the resident for the entry code. The 9th floor is fairly loud. The 6th floor tends to be the best.

• Most students just sleep on the couch in the pediatrics residents' lounge. Typical Schedule: • 1 week comp care inpatient. 1 week non‐comp care inpatient. 1 week PICU. 1 day/night NICU, 3

days in newborn nursery. • PICU: Rounds at 7am. Break at 8:30 for morning report. Continue rounds if interrupted. During day

fulfill plans from rounds. If you are on call, round with night team about 6pm, or whenever the new attending comes in. Otherwise go home when the residents tell you to.

• NICU: Monday morning, arrive for round at 7am (check before hand for time). Morning report at 8:30, noon lecture. Stay until end of rounds on Tuesday. Best to suggest to resident on‐call that you will be sleeping in the L&D med student call room, S229, and to please knock on the door when there is a code pink. You can give them your pager number and sleep somewhere else, but during a code pink they likely won’t have time to call you until it is over.

• Nursery: Morning report at 8:30. Dr. Swarup likely won’t arrive until 9‐9:30am. She will send you home, probably before 5pm.

• Inpatient: Be ready for rounds at 7am. You will pick up a patient or two on your first day and follow them for the duration of you time on the team. Walking rounds are after morning report. With the attending and residents you will go visit every patient. The rest of the day is spent writing notes, making phone calls, ordering labs, etc. When you go home depends on your resident, but generally is 5‐7pm.

• 7‐8am rounds. 8‐9am pediatrics morning report ‐‐ all the residents & students meet in a room to go over a case together. 9‐?? finish rounds if necessary. noon ‐‐ there is usually some type of noon conference. afternoons are for seeing new patients or following up on stuff for your old patients. you'll finish between 3 & 5pm, depending on whether you have anything to do.

Pearls of Wisdom: • Read whenever you can. This is a pretty busy rotation, so making the most of your study time is

important. Carrying around PreTest in your pocket is not a bad idea. • Be willing to write admin notes and discharge notes. If plans are developed for your patient, you

should carry them out when possible. If phone calls or labs need to be followed up, do it and report to your resident.

• No one takes attendance at morning report or noon conference, but these are really good learning opportunities you should take advantage of.

32

• When in outpatient clinics, ALWAYS VOLUNTEER TO GIVE IMMUNIZATIONS. There is no better time to practice than in well‐child clinic. In a single day you may administer up to 10 shots. You can get the nurses email address and log it into CAS. The nurses tend to be very impressed and give you a great eval.

Other comments: • Peds at Metro: Great to start out with. All of the residents from interns to the seniors were all laid

back, cool, and willing to go out the way to help. While on inpatient, I worked with Dr. M.L. Kumar. She's the I.D. Queen. We never needed an ID consult on our service because we had first hand all the bugs and killer drugs we needed to know. Great attending! As far as outpt., it's kind of hit or miss with who you work with and what you'll get to do. Urgent care is cool because you go in alone, get the pertinent HPI, present, treat, and call it a day!

• I think peds at Metro is a little disorganized as far as the day‐to‐day schedule but everyone is really nice and loves to teach. Also, you get to do a lot of hands‐on stuff – like respiratory antigen testing, blood draws, EKGs, etc.

Attendings: Dr. Gori is the very best attending. If you ever have the chance to work with him, jump on it. He is probably the best teaching attending at Metro on any service. Dr. Needleman likes to teach, especially about development since that is his specialty. However, he tends to be fairly long winded when there is not a lot of time. Try to measure how busy the clinic is before asking him lots of questions, because the clinic will get backed up. Dr. Smith is also a great teacher. He likes to pimp a lot, so you need to be on the top of your game. He expects very thorough presentations, and if you suggest a plan of action or a diagnosis, you should be prepared to explain your though process.

UH

Location: • Rainbow 5, 6, 7 Teams: • Green (General peds, neurology, cardiology) • From class of 2005 – (these have all changed but I’m not sure how):

o Red –heme/onc/ID o Green –pulmonary/gen peds o Orange –neurology/gen peds o Blue –cardiology/genetics/gen peds o Gold –endocrine/GI/gen peds

Call Schedule: • Q4 overnight call

33

Rounds: • Rounds are long because you have to round with each specialty (general peds, cardiology,

neurology, epileptology). We usually rounded from 8 to 11 am. Lecture: • Everyday at lunchtime. Lectures were run by senior residents, based on CLIPPS online cases. They

were helpful discussions of the cases we completed the night before (one case per night), with lots of time for questions and open discussion.

Where to Sleep: • Rainbow 3. Call rooms are private... you get your own room! Typical Schedule: • 7 am to 5 pm (when not on‐call)... 7 am to 1 pm the next day (on‐call) Pearls of Wisdom: • This is a wonderful rotation... work hard and enjoy it! • Peds at UH was pretty good. You have to choose which team you want to be on: Orange, Green,

Red, Blue and each has different specialties in addition to general pediatrics except for the Red team which is only Heme/Onc. So I do not recommend the red team if you want a broad experience. I did the Orange team and loved it. It has the most diverse experience and you see a lot of the most common peds. cases: asthma, diabetes. Also, since UH is a Cystic fibrosis center, you get a lot of good teaching about CF. The attendings were really good on the orange team. I've heard the Blue and green are also good.

• The other choice you get is where you want to do your outpatient. I did mine at the RAP clinic, which is the outpatient clinic in Rainbow where many of us did our 1st and 2nd year clinic with Dr. Boutry. She is a great preceptor and works with you in the mornings. In the afternoons, you stay there and do the sick clinic supervised by a senior resident. It is pretty good as long as the senior doesn't try to take over. So be aggressive. People who went to St.Luke's seemed to have a great experience too. It's definitely a well‐kept secret.

• So in addition to your 1 month inpatient, and 2 weeks outpatient, you'll get a week in the newborn nursery and a week in ENT. The nursery is a great opportunity to be recognized for your "competence" because they finally need you to help. It's a lot of fun and there's time for teaching. ENT is less interactive and you quickly learn that if you don't run after the team, you'll be lost in some stairwell in some wing of some building....

• There's a lot of tonsillectomies and Ear tube procedures. Make the most of it cause it may be your only chance to learn ENT. You can also go over to the Adult ENT surgeries if you feel that you can't take another tonsillectomy.

Attendings: Dr. Jeffrey Solomon Dr. Stephanie Chin Dr.Dell, the director, is very, very, nice and really wants this to be a great rotation. The lectures are useful and most of us used Blueprints and Appleton and Lange questions and Pre‐test questions.

34

Family Medicine Resources: • I didn't buy any textbooks for Family Medicine. Any of the handbooks for Internal Medicine

are useful, as are Harrison's and UpToDate. • Pocket Medicine, Boards and Wards

Metro Overview: • 8 weeks "Family Medicine":

o 2 half‐days OB clinic/week (1 with residents, 1 with attending) o 2 half‐days peds clinic/week (1 well‐child, 1 rapid access) o 3 half‐days Family Medicine clinic/week (with attending)

• The OB and peds outpatient clinics are part of your OB & peds grades, respectively, while only the Family Medicine clinics count towards your FM grade (that's only 2.5 weeks of total exposure to FM attendings to base your grade on!).

Location: • Both Pediatric clinics and the OB/GYN Resident clinic are at Metro Main Campus, in the outpatient

building across the street from the hospital. OB/GYN Attending clinics are at various satellite facilities. Family Medicine clinics may be at Metro Main Campus (in the basement of the hospital building) or at satellite facilities. There are some Spanish‐speaking clinics, which you can request if you are interested.

• Ground floor, across from E elevators Teams: • One on one pairings, 1 attending to 1 med student Call Schedule: no call; it's all outpatient. Rounds: N/A Lecture: • Wednesdays at 12 or 1pm for 3‐4 hours Typical Schedule: • See above. You get one half‐day/week of "reading time," which means you don't have anything

scheduled. • Generally, 8am‐5pm. Will have one half day off per week for reading. Pearls of Wisdom: • Family Medicine preceptors' schedules often change, so that they are not around for a couple of

weeks during your 8‐week experience. Talk with your preceptor about how to handle it ‐‐ some want you to go with another preceptor, others will have you make up the time during your reading day, others will tell you not to worry about it. There is this weird thing where, during the Family Medicine clinics, you are supposed to spend at least 1 half‐day shadowing a nurse instead of your

35

preceptor. In practice this doesn't work very well, but if you keep your eye out every week for patients you’ve seen for whom the nurse is giving shots, starting IVs, etc, you can just ask the nurse if you can help out with those tasks. Think of it as a chance for you to practice these skills.

• If you're interested in OB, let the FM coordinator know, because she may be able to assign you FM preceptors who do OB stuff & that way you can get even more practice than with just the OB clinics.

• Use the reading day to study everything, not just family. You don’t have as much time to study while on peds or OB/Gyn, so use your time while you have it. Make sure to read something about at least one patient every night.

• To get Honors, you need to be able to show that you went above and beyond expectations. Ways to do this are to call your patients with test results, go with them to get blood drawn or imaging studies done, volunteer to administer shots, review lab results and note them in a CAS log. Dr. Alexander is sure to ask about this.

• The shelf likes to ask preventative medicine questions, but all the questions are taken from the internal medicine question library selected by family practitioners. There are some peds and OB/Gyn questions thrown in, not too many, but you should try to prepare for that.

Attendings: Dr. Dasarathy ‐‐ FM Main Campus. Sees a lot of patients in a short amount of time; usually won't have you see more than 1 patient by yourself/day. The rest of the time she pulls you in with her, and has you do little things, like a focused pulmonary exam if the patient has a respiratory illness, or a pap smear. She does a lot of OB. She will let you do well‐child exams, which is nice, since often in Peds Well‐Child clinic you are just observing. Dr. Krofina ‐‐ FM Main Campus. Patient population largely male. Sees a lot of patients in a short amount of time; usually won't have you see more than 1 patient by yourself/day. The rest of the time he pulls you in with him and you are basically just observing. Dr. Alexander is amazing, very nice and a great teacher and mentor. She appreciates students who can tell when is the time to do a complete and thorough presentation, and when to use a pertinent positives summary. Dr. Adebambo is nice, but she will ask more questions and expect a higher level of performance, so make sure to read about patients you see with her. She will likely give you topics to read about, though might not ask about them later. It may be up to you to tell her what you learned. Dr. Lui is a great teacher, with clear expectations.

UH FM at SouthWest with Dr. White: Great guy, very easy to work with and loves to teach. He is nearing retirement and has some extra time in his schedule so things don't seem so rushed. You will get to help with a perform a lot of minor procedures including vasectomy, toenail removal, pelvic exams, colposcopies, and lots of liquid nitrogen. He also seems to know everyone in the hospital so if you have interests in other areas he can set you up to spend a few days of the rotation in whatever specialty you are interested in. Highly recommended!

36

FM at Kaiser in Lakewood Dr. Franko: He's okay but doesn't do many procedures ‐‐this has been primarily a shadowing experience. He is very laid back about grading and such, but if you want to learn anything hands on this may not be the location to do it at FM at Fairview hospital also is a Residency program. I worked with up to 18 residents and 6 attendings. So I had no continuity and switched preceptors every morning and afternoon. Some other people might like the different perspectives. I was disappointed by a lack of constructive criticism/feedback, which I feel was a direct result of the lack of continuity of preceptors. It is also frustrating to have different expectations all the time. I told them this in the evaluation that they asked me to fill out so it may change some. I suggested that they make one or two preceptors more primary and then fill in the gaps with the other ones. But I did get free parking! Although its at least a 30 minute drive to the West side, 40 buy the time you park and walk across the hospital to the office.

CCF Pretty much like everywhere else. I had Dr. Neides. This guy lets you do whatever you want. I had never even had surgery yet, and here I was making a dissection plane to get a lipoma out of some guy's forehead. Skin tag removal, punch biopsies, checking for corneal abrasions with that rad lamp. He will always watch you, it's not like he just turns you loose, but his idea of teaching is kicking you out of the nest. He won't answer questions a lot of times, and won't let you ask them, replying, "you're the doctor, you tell me." At first it's odd, but it really makes you think for yourself, and ends up being a lot more fun. So always have a treatment plan in mind before you start talking to him, and always know when the person's last PSA, mammogram, colonoscopy, Pap, etc. were (even when they are in for the sniffles or something), because he'll want to know.

Neurology

Resources:

• Many good resources provided during the course of the rotation • PreTest Neuro is ok for review, not enough by itself • Some form of microbio review as related to neuro (prominent on shelf) • Adams & Victor’s Principles of Neurology is available through AccessMedicine • High Yield Neurology • Blueprints in Neurology • Neurology syllabus/ outline for lectures—very useful since neuro writes their own exam and it is

not a shelf ‐ they test what they teach in lecture • Neurology Pre‐Test – This is a MUST before the exam, there is a huge difference between what

you are taught on this rotation and what is on the shelf, and this book will fill in the gaps that you need to learn

• I would recommend getting Greenberg’s Neurosurgery if you are interested, it has a lot more information condensed into one book than I was able to find elsewhere and it is in pocket book format.

Tools in your Pocket:

37

• Reflex hammer • Pen light • Pocket Eye chart • Sharp and dull objects (q‐tips work great) to test sensation • Mini‐mental reference sheet (to help you remember all the things to ask) • Stethoscope (you won’t need it very often, but the med student is the only one who ever has it) • Oto/opthalmascope – this is honestly the only rotation that I used it, but it came in very handy

when we couldn’t find another one • Pearl of wisdom: make a template for the full neuro exam (organized by mental status, motor,

sensory, cerebellar, etc.) so you can just fill it out as you do the physical exam on patients – it’s helps you stay organized during the exam and during your presentation.

Metro Location: • Inpatient neuro ‐ Hanna building (C elevator) 4th floor. • Peds Neuro – outpatient building, first floor by pediatrics in Area III. • Neuro surg – meet for rounds in radiology library on ground floor, between B and C elevators. • Neuro radiology – meet in main reading area. To get there, find the inpatient pharmacy between the

B and C elevators on ground floor, enter radiology and walk straight back. Turn right, first door on the right, second to last reading station.

Teams: • 2 weeks on inpatient neurology • 1 week on peds neuro • 3 days in neuro surgery • 2 days in neuro radiology. • Inpatient neuro and peds neuro are teams of 1 attending and up to 3 med students. • Neuro surg is 1 attending, probably 4 residents, and up to 3 med students. • Neuro radiology is 1 attending, 1 resident, and up to 3 med students.

Call Schedule: No call Rounds: • Neuro surg at 6am in radiology library • Neuro radiology at 8am in main reading rooms • Inpatient neuro completed in the afternoon after on‐call attending finishes morning clinic

Lecture: • Only on inpatient neuro, every morning from 7:30‐8am

Typical Schedule: • Inpatient neuro starts with lecture at 7:30, let out time depends on attending. Bahntge lets out 6‐

8pm, Hanna lets out 5‐6:30, Winkleman lets out 4:30‐6

38

Pearls of Wisdom: • On neuro surg, make sure to ask to scrub in if it seems appropriate and you are interested. Try to

find out the cases before you get there so you can review and ask questions. Best to talk to Jennifer Lastic about that on the Friday before you start.

• On inpatient neuro, make sure to read about at least one of your consults every day. Dr. Hanna will pimp you during lecture. It is in a friendly manner, but it helps to review the topic for lecture the night before.

• REVIEW MICROBIO FOR SHELF!!! There were many questions about this on the shelf you don’t get from pt encounters or lecture.

Attendings: • All attending are good, make sure to ask questions. • Hanna seems to pimp more than the others. • Bahntge is very methodical and takes his time and while he doesn’t tend to pimp as much, he is a

willing teacher.

UH Overview: • 4 weeks inpatient neuro: 2 weeks on general neuro inpatient service (also covers consults); 2 weeks

"elective" (neurosurgery, stroke service, or epilepsy service) • Stroke is dealing with purely patients who have had strokes (either prior or new). Consult dealt with

all of the other neurologic consults – MS, neuropathy, neoplasm. Neuro ICU is where they treat both bad pure neuro stuff and all the neurosurgery patients.

Location: • Lerner Tower 4 ‐‐ Neurosciences Intensive Care Unit (NSU) • Administration in Hanna House 5th floor Teams: • 1 team consisting of a 4th year, 3rd year, and 3x2nd year neurology residents, plus medical students

and possibly 1st year rotators from Internal Medicine and Psychiatry. • The main problem for us when I did it was that the teams were overcrowded. Team structure

depends on which 2wk blocks you get, as will the time and schedule. Call Schedule: • Stay until 9pm once a week. no overnight call. attend rounds 1 morning of the weekend. Rounds: • Begin at 8:30am or 6am Lecture: • 2‐4pm Thursday (neurosurgery topics), 9‐11:30am Friday (neurology topics), plus 8‐9am Friday

Neurology Grand Rounds. You are required to attend all these sessions (ie, if you're on neurosurgery, you still have to go to the neurology stuff & vice versa).

• Neurosurgery physical exam and lecture Th, Lectures all Friday morning (in IQ format)

39

Typical Schedule: • 8am preround on your patients

8:30 rounds begin. they can last anywhere from 1‐4 hours, depending on how many patients your attending wants to see with the team. after rounds, your job as a med student is to see consults, then present to the senior and eventually to the attending. I was the only med student on service, and I saw approx 1 consult/day. noon conferences on Tue & Wed: Stroke conference Tuesday; neuroradiology conference Wednesday

• Neurosurgery: o 5‐5:30 arrive to preround; 6‐7am rounds; 7:15 OR starts. spend rest of day in OR or taking

care of stuff on the floor/seeing consults. I was out by 4:30 almost every day, but when the service is busier, students stay later because surgeries run into the evening sometimes. On Wednesday mornings the neurosurgery residents have Conference from 7:30‐8:30, which is sometimes followed by lectures for the residents. Spine Conference Mondays 5pm; Neurovascular Conference Wednesdays 4pm.

o Arrive at 5 or 530 to pre‐round on a few patients (the ones you saw in surgery), round at 6‐7a, either go to a conference with the residents 1‐2x/wk or straight to the OR. No one will tell you to leave so you could leave at 5 or you could leave at 8 or 9 every night. Operations are usually many hours long, make sure you eat something between all of the cases and use the restroom. Many cases are run nearly entirely by senior residents ‐ find out which ones are more apt to let you do a lot and try to go with them on their cases.

• On the stroke team you'll be called for all the brain attacks and have to work up the patients using the NIHSS stroke scale, and on the gen neuro team you are more likely to have the opportunity to do things like lumbar punctures but you should be able to do both of these no matter which you are on (ask the residents). Essentially they are similar weeks. Pre‐round 6‐7a, round 7a‐??? hopefully done by 11‐12, attend a noon lecture 2‐3x/wk, and then just sit around waiting for new patients. Your best bet to get patients is always while on call so it's nice to take call early so you can establish a place for yourself on the team.

Pearls of Wisdom: • If you're interested, ask about Tumor Board and Neuropath Conference, both of which occur on

Wednesday afternoons. The team doesn't go, but if you're not doing anything, they may be interesting for you to attend.

• The neurosurgery residents are all very nice & are good teachers. You do, however, have to demonstrate interest for them to pay attention to you. Ask questions, be proactive about discussing which surgeries you want to go into. The attendings are also nice, and don't pimp too much. Don't be surprised that the attendings are not always present for the entire case ‐‐ a resident will frequently open and close by him/herself, with the attending only coming in for the middle of the case.

• Remember to always carry food in your pockets; neurosurgeries are really long, so eat when you can!

Neurosurgery is an intense but phenomenal experience. Hours are longer than neuro, typically 5:30am‐6 or 7pm, later if there are cases going on. The residents expect more than your normal surgery rotation, but will give you very explicit instruction on what they expect from you. The more you ask to do, the more they will let you (as in surgery in general). There is a huge emphasis in teaching, and all of the attendings are super nice.

40

Attendings: • You will only ever see attendings in the OR when you are in their cases. • Dr. Preston was the best attending I had in all my clerkships. He is an excellent teacher on rounds ‐‐

always reviews neuroimaging in detail, and uses patients' presentations as starting points for teaching pearls.

• Suarez: Be on time. He pimps residents more than students, but will ask students to look up stuff and teach the other residents/students. If there are no Neuro ICU cases, you will still have rounds for 1/2 an hour to go over everyones "homework."

• Lynch ‐‐ Nice doc who took the ward students aside every day and tried to teach us a few things about treatment of acute stroke in the afternoons.

• Devereaux: Really nice. Classic neurology teacher, talks for hours about a topic then goes to see the patient for 10 minutes to show us what he was just talking about. I learned a lot from him since he was very intent on teaching.

• Maddox: Also a nice guy, but was very busy. Rounds were shorter with him, more to the point and often much later in the day.

• Dr. Lerner – nice guy, a little eccentric at times. He is very interested in patient wellbeing, although this sometimes leads to longer rounds than with other attendings. He did come back for the med student after rounds to show neurologic exam

• Dr. Miller – Head of IQ+ for core 3, and extremely interested in research and teaching. His specialty is deep brain stimulation, but he does a little of everything.

• Dr. Hart – Also very into teaching, does spinal surgeries mostly • Dr. Cohen – Very interested in teaching. Has a very interesting office dedicated to Elvis. Does

pediatric surgeries • Dr. Robinson – Also pediatric surgeries Rainbow: Location: Rainbow 6 and 7, outpatient clinic in Beachwood, Westlake, Strongsville Teams: Orange team Call schedule: no call Rounds: round with Orange team depending on attending schedule, will do some consults and some clinic Lecture: Thursdays 11‐2:30 at UH Peds Neuro: Random assortment of attendings, all nice though. Hours are pretty good; round at 8:30, not much call to speak of or weekend work. May finish early may not depending on the number of consults and your resident’s efficiency.

Dr. Goyal, epileptologist, likes to ask you questions and will hit you if you get them wrong. Very friendly and knowledgeable. Can teach you everything about seizures and meds.

Dr. Bass, Super nice and always brings tasty treats to eat. Halloween is her favorite holiday. Dr. Green, also very nice. Quiet but highly efficient. Dr. Chwals, really seemed to like students the one day that I saw him. Seemed to enjoy being in

the teacher role Dr. Wiznitser, Better to work for than against. Reputation as a mean guy but was really cool with

the students and patients. Residents beware though.

41

Lectures: Every thursday all day you have lectures on the stuff that is on the test. The test is very reasonable IF you learn the objectives. Most people do well on it. Lectures are sometimes pressed for time, but like always, us med students just have to deal. Books: No required book, but having one was nice to refer to. I had a the Mass General Neuro Book; it was very to the point...you had to do neuro for a week to understand some of the stuff, but I liked it. some residents had "the little black book of neurology" by Dr. Daroff (UH/CWRU prof on neuro) and it seemed to have more words to explain stuff. those first two were pocket books and were 30 ‐35 bucks. Others used Blueprints and seemed to like it too. The emphasis was not too much on the complex neuroanatomy that we learned in second year, but have High Yield or Neuro Made Simple to look over, just for a refresher.

CCF You will be on the Neuro consult team, so you spend your day running around the hospital seeing patients on other services. You will be put in the rotation for patients along with the interns, so you’ll have plenty of work. The pearls at the beginning of this section are good ones. Be sure to know how to use Epic and pull up the Neuro consult template. It will make your notes excellent. I believe we had to get to the hospital around 8 and usually left around 5:30. I don’t remember well. Lectures were Friday mornings, so we had no clinical work these days. You are required to take call with the floor Neuro team twice. Pretty easy. You also spend a few days in a variety of outpatient clinics. These were fairly laid back clinic schedules with attendings who usually let you do a lot. You get to do one afternoon with a Neuro or spine surgeon and spend one morning in the OR. So if you are looking for a neurosurgery experience, rotate elsewhere. The attendings were great. They took time to teach with each patient and had reasonable expectations for the students. They don’t fill out your CAS forms. All in all I was very happy with my Neuro rotation.

Psychiatry Resources: • Lange General Psychiatry • PreTest Psychiatry – good quick review for shelf • First Aid for the Psych Clerkship • Some specific source for anti‐psychotic drugs with all side effects/dosing/etc • Blueprints in Psychiatry • High Yield Behavioral Sciences

Metro Location: • Outpatient in Hanna building, 7th floor. Inpatient in 6B

Teams: • Inpatient, Erhardt and Goddesman; Consult, Weiss and Ionescu. Inpatient is 1 attending, 1 resident,

and up to 2 med students. Consult is 1 attending, 1 resident, and up to 2 med students.

42

Call Schedule: • One weeknight call on consult, one weekend and one weeknight call on consult. The weeknight call

is only until 11pm and weekend is just for morning rounds, maybe 7‐12.

Rounds: • Consult service does combined rounds at 1pm. You need to have seen all your old patients and any

new consults by this time if possible. Inpatient service rounds in the morning when the attending arrives then once in the early afternoon.

Lecture: • For consult service, there is a morning (8:30) and noon lecture. • For inpatient, noon lecture and then often the attending will take time to give a lecture on the fly.

Where to Sleep: • Generally med student call room on 6th floor (601B) is a good choice, but you don’t have to stay

overnight for this rotation. Call only lasts until 11pm.

Typical Schedule: • Inpatient psych, arrive early enough to round on your team’s patients to be ready for rounds at 8am,

stay until afternoon rounds are complete and you have finished your notes and discharges (generally 5‐6pm).

• Consult service, morning lecture at 8:30, round on your patients and new consults, lecture at noon, team rounds at 1pm. When you leave depends on the attending: Weiss out by 4:30‐5, Ionescu out by 5‐9.

Pearls of Wisdom: • Read something about at least one patient every night. It doesn’t matter where you read it

from, or even if you finish a full book by the end of the rotation, as long as you read something. • For the shelf exam, know the neurotransmitters associated with disorders and drugs. Know

timelines for disease for shelf, such as how long you needs symptoms to diagnose depression. There tend not to be questions about different schools in psychiatry, like Erikson vs Freud.

Attendings: Weiss is a great teacher and is super fast on rounds, TRY TO GET ON HIS TEAM. Ionescu doesn’t teach much, is easily distracted, and takes forever on rounds; nice guy but a pain to be on his team. Erhardt loves neurotransmitters, and is super impressed when you know which meds affect which neurotransmitters and if there is a chemical basis for different conditions.

43

UH Location: • Richmond for inpatient and UH for consult Teams: • Consult service or inpatient psych unit Call schedule: • Approximately 1 call/ week for inpatient only, and it was only until 9 or 10pm Rounds: • Morning rounds with team at 9 am Lecture: • Once per week on Friday mornings The UH psych rotation was BY FAR the most organized of any rotation I have had up to this point. Kelly Kelley (sic) notified you about everything well before it took place, so there was no guess work on expectations and minimal last minute changes. This rotation was split into two two week segments. The inpatient was in Richmond heights, about 30 minutes away from the UH campus since Hanna Pavillion no longer exists. There are two teams, adult psych and geriatric psych. Geriatric is mostly dementia and depression, where as you get more psychotic and depression on adult. We generally had up to 4 patients at a time, where you would pre‐round before morning lecture at 8am and then round at 9am (although some attendings didn’t show up until 10 or later, so you could round after morning lecture). Rounding is different than other areas in medicine where the patient is actively involved in the process. One morning you do ECT, which is a very valuable experience. Overall the atmosphere was very relaxed. The other half involves psycho consult. Here we begin at 8:30 and round usually until noon. While the goal is to round together, there is often a divide and conquer approach in order to get all of the patients in. In the afternoons, they take consult, which they will let you do but only when a resident is present. Attendings: Dr. Ramirez (Richmond) – Great attending, will often bring food and talk about very interesting issues in psych and just the world in general Dr. Agle (UH) – Soft spoken, but do not think that this means he is not listening or interested. Dr. Lacamp (UH) – coordinator of psych at UH, the opposite of Dr. Agle in that she has a lot of energy throughout the day

44

45

VA (Brecksville) Location: • Locked wards but you are otherwise in the med student work rooms where each student has their

own computer and desk to work at the whole time (which is very nice and unique) Teams: • 1‐2 students per attending, no residents Call Schedule: None, no weekends Rounds: • "rounds" are the only time you and the attending really interact with the patients on the locked

ward Lecture: • 1‐2x/week in the afternoon for 2 hours

Typical Schedule: • Rounds at 8 (sitting in a conference room w/ your attenting and speaking to each patient for a few

minutes), write‐up notes on your patients from the rounds, admit new patients, meet with attending to go over your notes/plans for your patients that day, leave by 4 usually

Pearls of Wisdom: • Great experience because the amount you're able to do without a resident above you Attendings: Konicki ‐ a man of few words, will sometimes just stare at you and say nothing w/ very long pauses waiting for you to say something; lets you handle your patients completely and argue for the types of drugs you think they should be on, very laid back and enjoyable, conducts very fast rounds and is the only one talking during the rounds usually.

CCF Like neuro, you are on the consult team, working up patients on other services. You will be put in the rotation will all the interns, who are usually from other services rotating through Psych. You will get pages from the nurse practioners about patients for you to see. Take a detailed psych history, including social background, religion, family life, drug use, etc., etc. Any collateral information you can get from family, or by calling the patients primary team, or even their PCP off‐site, will make you look very good. When you are presenting your patient, intro this information by saying, “and I got some collateral information from the patient’s PCP in Lorain, who says…” You’ll look like a rock star. The more thorough you are the better you will look. Be sure to know the basics of using Epic, especially how to pull up the Psych consult note template. Because the interns are from other services, they won’t have a lot of experience beyond you. The senior psych resident or fellow on your team can be excellent resources. For the most part the attendings are very good. Dr. Pozuelo and Dr. Viguera stick out in my mind as very good. Dr. Coffman knows a lot, but also loves to hear herself talk. Rounding will take forever with her. Also, she will want to know the patient’s life story, literally. Get lots of info. You also spend a week at their inpatient psych facility out on West 25th. This is very easy. You’ll be there from 8:30am to about noon. Enjoy it.

Third Year Survival Guide 02-2010

Documents

Transcript of Third Year Survival Guide 02-2010